Provider Demographics
NPI:1649446360
Name:TILLEY, JAN L (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:L
Last Name:TILLEY
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30063 CLOUD VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163-4031
Mailing Address - Country:US
Mailing Address - Phone:210-545-4422
Mailing Address - Fax:210-545-4495
Practice Address - Street 1:400 N LOOP 1604 E
Practice Address - Street 2:SUITE 175
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1258
Practice Address - Country:US
Practice Address - Phone:210-545-4422
Practice Address - Fax:210-545-4495
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04462133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered